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Systematic Review and Meta-Analysis of Extraperitoneal Versus Transperitoneal Colostomy for Preventing Parastomal Hernia

Kroese, Leonard F. M.D.1; de Smet, Gijs H. J. B.Sc.1; Jeekel, Johannes M.D., Ph.D.2; Kleinrensink, Gert-Jan Ph.D.2; Lange, Johan F. M.D., Ph.D.1,3

Diseases of the Colon & Rectum: July 2016 - Volume 59 - Issue 7 - p 688–695
doi: 10.1097/DCR.0000000000000605
Current Status

BACKGROUND: Parastomal hernia remains a frequent problem after constructing a colostomy. Current research mainly focuses on prophylactic mesh placement as an addition to transperitoneal colostomies. However, for constructing a colostomy, either an extraperitoneal or transperitoneal route can be chosen.

OBJECTIVE: The aim of this meta-analysis was to investigate which technique results in lower parastomal hernia rates in patients undergoing end colostomy.

DATA SOURCES: A meta-analysis was conducted according to Preferred Items for Reporting of Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Embase, MEDLINE, Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane, PubMed, and Google Scholar databases were searched. The study protocol was registered in the International Prospective Register of Systematic Reviews database.

STUDY SELECTION: Studies comparing extraperitoneal and transperitoneal colostomies were included. Only studies written in English were included. The quality of studies and risk of bias were assessed using the Cochrane risk-of-bias tool. The quality of nonrandomized studies was assessed using the Newcastle–Ottawa Scale.

INTERVENTION: The intervention was colostomy formation.

MAIN OUTCOME MEASURES: The main outcome measure was parastomal hernia incidence. Secondary outcome measures were stoma prolapse, stoma necrosis, and operating time.

RESULTS: Of 401 articles found, a meta-analysis was conducted of 10 studies (2 randomized controlled trials and 8 retrospective studies) composed of 1048 patients (347 extraperitoneal and 701 transperitoneal). Extraperitoneal colostomy led to significantly lower parastomal hernia rates (22 of 347 (6.3%) for extraperitoneal versus 125 of 701 (17.8%) for transperitoneal; risk ratio = 0.36 (95% CI, 0.21–0.62); I2 = 26%; p < 0.001) and significantly lower stoma prolapse rates (2 of 185 (1.1%) for extraperitoneal versus 13 of 179 (7.3%) for transperitoneal; risk ratio = 0.21 (95% CI, 0.06–0.73); I2 = 0%; p = 0.01). Differences in stoma necrosis were not significant. Operating time data were insufficient to analyze.

LIMITATIONS: Most of the studies were nonrandomized, and some were not recent publications.

CONCLUSIONS: Although the majority of studies included were retrospective, extraperitoneal colostomy was observed to lead to a lower rate of parastomal hernia and stoma prolapse.

1 Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands

2 Department of Neuroscience, Erasmus University Medical Center, Rotterdam, the Netherlands

3 Department of Surgery, Havenziekenhuis, Rotterdam, the Netherlands

Financial Disclosure: None reported.

Correspondence: Leonard Kroese, M.D., Department of Surgery, Room Ee-173, PO Box 2040, Erasmus MC, University Medical Center, 3000 CA Rotterdam, the Netherlands. E-mail:

© 2016 The American Society of Colon and Rectal Surgeons